PLOS Clim plos plosclimate PLOS Climate 2767-3200 Public Library of Science San Francisco, CA USA 10.1371/journal.pclm.0000412 PCLM-D-23-00235 Research Article Earth sciencesAtmospheric scienceClimatologyClimate changeAnthropogenic climate change Earth sciencesAtmospheric scienceClimatologyClimate change Social sciencesSociologyEducationMedical education Medicine and health sciencesMedical humanitiesMedical education Medicine and health sciencesHealth careEnvironmental health Medicine and health sciencesPublic and occupational healthEnvironmental health Ecology and environmental sciencesPollutionAir pollution Medicine and health sciencesPublic and occupational healthBehavioral and social aspects of health Biology and life sciencesNeuroscienceCognitive scienceCognitive psychologyLearningHuman learning Biology and life sciencesPsychologyCognitive psychologyLearningHuman learning Social sciencesPsychologyCognitive psychologyLearningHuman learning Biology and life sciencesNeuroscienceLearning and memoryLearningHuman learning Research and analysis methodsResearch designSurvey researchSurveys Climate Change, Environment, and Health: The implementation and initial evaluation of a longitudinal, integrated curricular theme and novel competency framework at Harvard Medical School Climate Change, Environment and Health: A novel curriculum at Harvard Medical School https://orcid.org/0000-0003-1974-9276 Kline Madeleine C. Conceptualization Data curation Formal analysis Investigation Methodology Project administration Writing – review & editing 1 2 ‡ Malits Julia R. Conceptualization Data curation Formal analysis Investigation Methodology Project administration Writing – review & editing 1 3 ‡ https://orcid.org/0000-0001-8941-5349 Baker Natalie Conceptualization Data curation Formal analysis Investigation Methodology Project administration Writing – review & editing 1 https://orcid.org/0000-0002-6193-665X Shirley Hugh Conceptualization Data curation Formal analysis Investigation Methodology Project administration Writing – review & editing 1 https://orcid.org/0000-0002-4416-6243 Grobman Ben Conceptualization Data curation Formal analysis Investigation Project administration Writing – review & editing 1 https://orcid.org/0000-0002-9467-8394 Callison William Éamon Conceptualization Data curation Investigation Project administration Writing – review & editing 1 Pelletier Stephen Formal analysis Investigation Methodology Writing – review & editing 1 https://orcid.org/0000-0002-2146-2955 Nadeau Kari Conceptualization Formal analysis Methodology Supervision Validation Writing – review & editing 2 4 https://orcid.org/0000-0003-0039-7784 Jones David S. Conceptualization Formal analysis Investigation Methodology Writing – review & editing 1 4 https://orcid.org/0000-0002-7531-4886 Basu Gaurab Conceptualization Data curation Formal analysis Investigation Methodology Supervision Writing – original draft 1 2 5 * Harvard Medical School, Boston, Massachusetts, United States of America Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America Department of Emergency Medicine, Massachusetts General Hospital/Brigham and Women’s Hospital, Boston, Massachusetts, United States of America Harvard University, Cambridge, Massachusetts, United States of America Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts, United States of America Harper Sherilee L. Editor University of Alberta, CANADA

The authors have declared that no competing interests exist.

‡ MCK and JRM contributed equally and are co-first authors.

 * E-mail: gbasu@challiance.org 29 5 2024 2024 3 5 e0000412 27 11 2023 8 4 2024 2024 Kline et al This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Climate change, air pollution, and ecological degradation impact health through numerous, complex mechanisms. To train future physicians to understand these impacts, medical schools can deliver longitudinal climate curricula in undergraduate medical education, but the field remains nascent. This report describes the development, implementation, and evaluation of the longitudinal, integrated Climate Change, Environment, and Health curricular theme and novel competency framework at Harvard Medical School (HMS). A group of HMS students collaborated with faculty to integrate climate content into the pre-clerkship curriculum. The team subsequently pursued institutional recognition as a formal HMS curricular theme and created a new competency framework that guided curriculum integration mapping and evaluation tool development. The competencies cover the impact of climate change, air pollution, and ecological degradation on health in the context of historical and structural inequities and explore the role of healthcare in contributing to both climate change and solutions. A retrospective, eight-item survey using a seven-point Likert scale and two open-ended questions was administered at the end of the pre-clerkship curriculum. HMS approved a required, four-year Climate Change, Environment, and Health curricular theme in January 2023. Survey data from 100/134 (74.6%) study participants showed that most students agreed (somewhat agree/agree/strongly agree) the curricular theme was valuable (76.0%) and improved their understanding of the health impacts of climate change (80.0%). Most students agreed that their abilities in the five competencies improved because of exposure to the curricular theme. Qualitative comments indicated that students found the curriculum valuable, and also provided constructive feedback. Efforts to expand the curriculum to all four years of medical school and conduct further evaluation continue. Further scholarship is needed to present different curricular approaches and competency frameworks, which can ultimately support effective training of future physicians to understand and respond to the impacts of climate change on health and health equity.

 http://dx.doi.org/10.13039/100000057 National Institute of General Medical Sciences T32GM144273 https://orcid.org/0000-0003-1974-9276 Kline Madeleine C. MK was supported by award number T32GM144273 from the National Institute of General Medical Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of General Medical Sciences or the National Institutes of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Data Availability We have the raw data available in the submission and submitted as a supporting file. Introduction

Climate change is a present and escalating public health crisis. The World Health Organization (WHO) has described climate change as the single greatest health threat facing humanity [1]. The combined effects of climate change, air pollution, and ecological degradation have devastating consequences on human health, including severe weather events, extreme heat, poor air and water quality, altered crop yields and reduced food security, changes in vector ecology, and social conflict [2]. Critically, climate change, air pollution, and ecological degradation are issues of health equity that intersect with systemic forces such as structural racism, income inequality, and environmental injustice to exacerbate existing health inequities. For example, communities historically impacted by redlining experience greater health risks associated with increased exposure to oil and gas wells, higher levels of pollution, less residential tree cover and green space, and warmer surface temperatures in their neighborhoods [3].

The threat of climate change also has significant implications for the practice of medicine. To effectively care for patients, physicians must understand the ways in which climate change impacts health and be prepared to apply that knowledge through preventive care, diagnostic reasoning, and risk reduction counseling. Physicians’ role in the climate crisis is especially critical as they have been shown to be among the most trusted voices on climate action [4].

In recent years, there has been increasing awareness of the need for climate education in medical training and interdisciplinary health professions. There is a burgeoning literature documenting progress made in climate education across the medical, nursing, and public health fields, among others. For example, public health scholarship has formulated competency frameworks [5, 6]. In the field of nursing, thought leaders have described the challenges of integrating climate education [7], advocated for educational competencies [7] and provided recommendations for developing robust climate education for nursing students [7].

In undergraduate medical education, frameworks for educational concepts, competencies, and innovation in climate education have been described [8–10]. Internationally, institutional efforts to integrate climate education into medical school curricula have been reported [11, 12]. Large surveys have evaluated climate change and planetary health educational initiatives in medical schools globally, [13] and nationally, including the United Kingdom, [14] Australia, [11] and Ireland [15]. In Canada, national surveys were used to understand medical students’ experiences, attitudes, and interests in climate health education [16]. The importance of innovation in climate education in graduate medical education and post-residency fellowships has also been described [17–19]. These frameworks and curricular advances can further support students and practitioners’ career development in climate related advocacy, policy, research, and education, among other opportunities.

Among U.S. medical schools, there is increasing recognition of the importance of undergraduate medical education in preparing future physicians to incorporate knowledge of climate change’s impacts on health into their clinical practice.

A survey by the Association of American Medical Colleges (AAMC) showed that 55% of U.S. medical schools self-reported that the health effects of climate change was a required topic in pre-clerkship and clerkship courses in 2022, more than double the 27% of medical schools that reported such a requirement only two years prior [20]. Medical schools have begun to describe innovations in climate change curricula, which has been largely driven by medical students, but the field remains nascent [21–26]. Further dissemination of educational innovation reports may inspire medical school administrations to commit to developing climate curricular integrations that are appropriate to their specific context. Continued scholarship in this field is also essential to the development of broadly accepted competency frameworks that are endorsed by medical societies and accreditation bodies and can be readily applied by medical schools nationwide.

To respond to this need, we describe an educational innovation at Harvard Medical School (HMS)—the development, implementation, and evaluation of the longitudinal, integrated HMS Climate Change, Environment, and Health curricular theme. We further describe the process of mapping the curriculum onto a newly developed competency framework.

 Approach and methods Background

Climate medical education was first developed at HMS by the Center for Health and the Global Environment, which was established in 1996. However, in the past decade, HMS offered only ad hoc climate content from a small group of faculty. In 2021, Students for Environmental Awareness in Medicine (SEAM), a medical student group at HMS, conducted an informal poll that found strong interest in climate medical education among their classmates. SEAM presented a proposal for a comprehensive climate curriculum to faculty leadership in August 2021, which was positively received. They subsequently led the development of a pilot lesson on the association between exposure to outdoor air pollution and the pathophysiology of asthma, which consisted of a pre-class preparatory video and assigned questions co-created by students and faculty. Students also secured a faculty mentor to oversee faculty efforts on curricular reform. To draw upon a wider range of expertise, the faculty mentor organized a climate health faculty working group (CHFWG). In August 2022, SEAM and the CHFWG began work with the goal of integrating climate content into every course in the first year of medical school training. With encouragement from the Dean of Medical Education, we began a collaborative process of curricular content development and also began seeking status as a formal curricular theme at HMS, which would help accelerate the development of a formal, required, and sustained curriculum. We received formal recognition as a HMS curricular theme in January 2023. The cohort described and evaluated in this manuscript received exposure to their final pre-clerkship climate curricular integration in September 2023.

 Content and pedagogy of longitudinal, integrated curriculum

In the Spring of 2022, SEAM and CHFWG members began co-developing a longitudinal climate curriculum. The initial priority for our curriculum was to lay a strong conceptual foundation in the pre-clerkship phase of the Pathways curriculum track (HMS’s main track) and then subsequently expand climate education into the clerkship and post-clerkship phases and the Health Science and Technology (HST) curriculum track (a joint program with Massachusetts Institute of Technology). The pre-clerkship phase refers to the initial set of classroom-based courses taught in medical school—including anatomy, physiology, immunology, molecular biology, and social sciences—that precedes core clinical rotations. The clerkship phase refers to the collection of core clinical rotations—including internal medicine, pediatrics, surgery and obstetrics/gynecology—that are carried out in clinical settings, such as hospitals and ambulatory care centers. The final climate curriculum that was delivered in the 2022–2023 academic year is outlined in Table 1.

10.1371/journal.pclm.0000412.t001 Description of course-specific Climate Change, Environment, and Health curricular (CCEH) theme integrations in the pre-clerkship curriculum.
Course Course Description CCEH Integration: Content CCEH Integration: Format  CCEH Competency (See Table 2)
Introduction to the Profession An orientation for first-year medical and dental students to teach professionalism expectations as physicians in training Advocacy and activism through a climate lens  Lecture, facilitated small-group breakout session 1,2,3,5
Foundations Integrated basic science course focusing on multiple disciplines, including molecular biology, biochemistry, pharmacology, histology, anatomy, immunology, genetics, and microbiology Land use change and malaria Integrated additions to the preparatory reading and in-class clinical vignette as part of case-based learning 1,2,3
Immunology in Defense and Disease Foundational course focused on dermatology rheumatology, allergy, and immunology Allergic rhinitis and climate change  Integrated additions to the preparatory materials and existing clinical vignette  1,2
Practice of Medicine Longitudinal clinical skills course, focused on history-taking, physical exam, clinical reasoning, and primary care Exposure history and heat risk screening questionnaire  Preparatory materials to be reviewed with preceptor during clinic 1,2
Essentials 1 Integrated social sciences course focusing on clinical epidemiology, health policy, social medicine, and medical ethics Environmental justice and global climate justice Integrations into small group discussion materials, two optional talks on climate policy and environmental justice 3,4,5
Homeostasis 1 Physiology and pathophysiology course covering pulmonology, cardiology and hematology Air pollution, asthma, and CAD*  Preparatory concept video, assessment question, consolidation exercise, expansion of existing clinical vignette 1,2,3
Homeostasis 2 Physiology and pathophysiology course covering nephrology, gastroenterology, and endocrinology Climate change, dehydration, and MeN**/CKDu*** Assessment question and consolidation exercise 1,2
Mind, Brain, and Behavior  Physiology and pathophysiology course covering neurology and psychiatry Climate change, and mental health  Preparatory video, assessment question 1,2
Transition to the Principle Clinical Experience A preparatory course for students entering the core clinical clerkships Healthcare sustainability focused on surgical waste, heat stress among the elderly, air pollution and environmental impacts on cardiovascular disease Integrations into case-based sessions and small group discussions 1,2,3,4,5

Abbreviations

*CAD = coronary artery disease

**MeN = Mesoamerican nephropathy

***CKDu = chronic kidney disease of unknown etiology

Our pedagogical approach intentionally focused on longitudinally integrating content into pre-existing course materials rather than developing an isolated, immersive course. The benefits of such pedagogy has been demonstrated in the literature [27]. The pedagogical principles of spacing and interleaving were used. Spacing is a teaching practice in which learning is distributed over time, rather than in a consolidated block [28]. Interleaving is a teaching practice that emphasizes the value of exposure to a variation of topics [29]. In an interleaving educational approach, learners engage with a specific topic, then leave that topic to learn new topics, and then return to the previous topic for further learning. Both spacing and interleaving practices encourage revisiting material with breaks in between. They were chosen because evidence has shown that they can enhance retention of information and increase capacity to create connections between concepts [29]. This integrated pedagogical approach also allowed for climate curriculum to be embedded without significant displacement of other educational topics, which was greatly valued by course directors. The format of curricular integrations varied widely and included lecture-based sessions, case-based learning, small group discussions, and clinic-based precepting exercises (Table 1). Moreover, climate content was designed to be relevant to the diverse professional interests of medical students and challenged students to develop an active practice of examining how climate change impacts their professional experiences and interests within medicine.

In the 2022–2023 academic year, the pre-clerkship curriculum described the health impacts of climate change, air pollution, and ecological degradation on the following: vector borne disease, heat stress, mental health, food security, water scarcity, renal disease, allergic rhinitis, asthma, and coronary artery disease. Sessions also highlighted the role of physician advocacy on climate change policy and included a student-led small group discussion addressing hospital sustainability. Throughout the longitudinal curriculum, the intersections of climate change and global health equity, environmental justice, structural racism, and community partnership were emphasized, especially in relationship to Black, Indigenous and immigrant communities.

 Curricular design process

SEAM and the CHFWG jointly approached course directors approximately six months prior to the start of each course, providing a rationale for climate medical education and presenting opportunities for climate curricular integrations. Workshop meetings were subsequently scheduled in which students presented ideas for climate integrations. CHFWG members provided climate and health expertise, and course directors offered insight on course priorities, including medical topics taught in the course and any relevant time constraints. These workshop meetings were structured intentionally with a spirit of co-creation among students and faculty with complementary knowledge bases and skill sets. The group explicitly discussed concerns they had about the impacts of climate change on the health of patients, which helped develop a sense of shared purpose and unified vision. Every course director that we solicited responded favorably to the outreach, resulting in new climate content integration into every course for which it was requested (Table 1). SEAM and CHFWG members also prepared a climate and health faculty development session for HMS faculty, organized by the office of the HMS Dean of Faculty Development. After the completion of each curricular integration, SEAM and the CHFWG solicited feedback from teaching faculty regarding their experience delivering the material and that of students receiving the material.

 Competency framework

In parallel with curriculum design, the CHFWG and SEAM collaborated to develop a novel competency framework (Table 2). We began by conducting a landscape review of pertinent scholarship of climate education in U.S. medical schools [21–26]. After developing an initial framework, we used an adapted Delphi process to facilitate iterative feedback from stakeholders, including faculty, students, and the Dean of Medical Education. Our competency framework sought to reinforce the medical school’s existing medical education competencies. Our framework includes competencies addressing not only the impact of climate change on clinical practice, but also ones addressing how historical and structural factors exacerbate climate-related health inequities, how the healthcare system contributes to and is vulnerable to climate change, and how health professionals and institutions can contribute to climate solutions. Learning objectives were developed to accompany each competency. Once completed, the competency framework was used by faculty and students to map curricular integrations and develop new evaluation tools.

10.1371/journal.pclm.0000412.t002 Description of the HMS Climate Change, Environment, and Health curricular theme competencies and learning objectives.
HMS Climate Change, Environment and Health Curricular Theme Competencies and Learning Objectives Corresponding HMS MD Program Competencies
Competency 1: Define the pathophysiological mechanisms by which climate change, air pollution and ecological degradation impact human healthBy graduation, students will be able to: 1. Explain the ways by which climate change impacts human health through environmental exposure pathways including natural disasters/extreme weather, changes in water quality and quantity, food insecurity, heat stress, air pollution, and vector-borne diseases 2. Describe the impact of climate change, air pollution, and ecological degradation on health outcomes including cardiovascular, respiratory, reproductive, neurologic, immunologic, psychiatric, oncologic, and infectious disease processes 3. Identify risks for disease emergence, especially zoonoses, that arise from ecological degradation in the form of deforestation, land use changes, pollution, and biodiversity loss • Medical Knowledge• Critical Thinking and Inquiry
Competency 2: Apply knowledge of climate impacts on human health to the clinical care of patients including prevention, diagnosis, and risk reduction counselingBy graduation, students will be able to: 1. Take a clinical history of environmental exposure risks related to occupation, residence, local environmental hazards and indoor pollutants 2. Develop clinical prevention and treatment plans for extreme heat and air pollution exposure based upon identification of at-risk patients, including patients with underlying morbidities and inequitable social determinants of health 3. Establish plans to address excess burdens of psychiatric disease that arise from climate change influenced extreme weather events such as heat waves, wildfires, more severe hurricanes, and flooding • Medical Knowledge• Patient Care• Interpersonal and Communication Skills• Organizational and Social Determinants of Health 
Competency 3: Analyze the historical and structural causes of climate change, air pollution and ecological degradation, and describe the ways in which it creates/exacerbates health inequityBy graduation, students will be able to: 1. Explain ways that climate change intersects with structural racism and health equity in the United States (e.g. redlining, heat islands, disproportionately impacted populations, intersecting health challenges, access to adaptive and protective measures) 2. Define environmental justice and recognize its importance to climate health solutions 3. Describe impacts of climate change on global health inequities (natural disasters/extreme weather, forced migration, political conflict, food security, water scarcity, and sea level rise), including inequitable resource allocation for adaptive responses • Critical Thinking and Inquiry• Organizational and Social Determinants of Health
Competency 4: Describe the ways in which the health care system contributes to climate change and how healthcare delivery is vulnerable to climate-related eventsBy graduation, students will be able to: 1. List ways in which the delivery of healthcare creates greenhouse gas emissions, pollution, environmental toxicants and waste 2. Explain how climate change can interfere with the delivery of healthcare through effects on access to care and impacts on healthcare facilities and supply chains • Interpersonal and Communication Skills• Critical Thinking and Inquiry• Organizational and Social Determinants of Health Care
Competency 5: Explore roles health professionals and institutions can play in climate solutionsBy graduation, students will be able to: 1. Communicate the health and health equity co-benefits of climate solutions to the general public, policy makers and patients and address climate science misinformation 2. Identify health system-based interventions that mitigate healthcare greenhouse gas emissions and adapt healthcare delivery to a changing climate . Examine potential roles in contributing to climate solutions, including climate responsive clinical care, research, health systems sustainability, resilience, education, communication, community partnership and advocacy/policy • Professionalism• Interpersonal and Communication Skills• Organizational and Social Determinants of Health Care
Evaluation methodology

A retrospective survey was administered in late August and early September 2023 after the final pre-clerkship climate- related curricular integration was presented to the first-year student cohort. While in the classroom, students were provided with a QR code that linked the survey questions. Participation in the survey was optional and the sole eligibility criteria was enrollment in the Pathways track. The HMS Program in the Medical Education’s Educational Scholarship Review Committee deemed this project to be quality improvement and therefore exempt from IRB review. We obtained students’ written informed consent to participate in the evaluation by placing the following statement prior to survey questions, “By participating in this survey, you consent to having your de-identified responses, analyzed solely in the aggregate, used in publications on this curriculum.” We used an eight-item survey to assess students’ perceived belief in the importance and value of the curriculum and their belief in how the curriculum impacted their development in the five curricular theme competencies. A seven-point Likert scale was used for responses to survey questions. Students were also provided with open text fields to comment on their perceived value of the curricular theme and share any additional thoughts. The data was accessed on September 2, 2023 for research purposes and authors did not have access to information that could identify individual participants during or after data collection.

We analyzed the survey results for 100 of 134 (74.6%) eligible students who participated in the evaluation. We analyzed the descriptive statistics for all quantitative items (Table 3) using IBM SPSS Statistics for Windows, Version 28.0, Armonk, NY: IBM Corp. Responses to open-ended questions were reviewed for quality improvement.

10.1371/journal.pclm.0000412.t003 Retrospective survey responses assessing importance, value and impact of the HMS Climate Change, Environment and Health curricular theme pre-clerkship content among HMS pre-clerkship students in Pathways track, Boston, MA, 2023 (n = 100).
StronglyDisagreeN (%) DisagreeN (%) SomewhatDisagreeN (%) Neither agree or disagreeN (%) Somewhat AgreeN (%) AgreeN (%) Strongly AgreeN (%) Percentage Somewhat Agree/ Agree/ Strongly Agree 95% CI
Prompt for the following questions:To what extent do you disagree or agree with the following statements?
Understanding how climate change impacts human health should be part of all students’ medical education.a 2 (2.0) 2 (2.0) 0 2 (2.0) 19 (18.8) 38 (37.6) 38 (37.6) 94.1 90.7–99.3
The Climate Change, Environment, and Health curricular theme was a valuable part of my pre-clerkship medical education. 4 (4.0) 1 (1.0) 5 (5.0) 14 (14.0) 31 (31.0) 33 (33.0) 12 (12.0) 76.0 67.6–84.4
Because of the Climate Change, Environment, and Health curricular theme, my understanding of the health impacts of climate change has improved during my pre-clerkship coursework at medical school. 3 (3.0) 2 (2.0) 4 (4.0) 11 (11.0) 24 (24.0) 38 (38.0) 18 (18.0) 80.0 72.2–87.8
Competency 1:Because of the Climate Change, Environment, and Health curricular theme, I am better able to define the pathophysiological mechanisms by which climate change, air pollution and ecological degradation impact human health. 2 (2.0) 2 (2.0) 5 (5.0) 11 (11.0) 35 (35.0) 31 (31.0) 14 (14.0) 80.0 72.2–87.8
Competency 2:Because of the Climate Change, Environment, and Health curricular theme, I am better able to apply knowledge of climate impacts on human health to the clinical care of patients, including prevention, diagnosis, and risk reduction counseling. 2 (2.0) 3 (3.0) 5 (5.0) 14 (14.0) 33 (33.0) 33 (33.0) 10 (10.0) 76.0 67.6–84.4
Competency 3:Because of the Climate Change, Environment, and Health curricular theme, I am better able to analyze the historical and structural causes of climate change, air pollution, and ecological degradation, and describe the ways in which it creates/exacerbates health inequality. 2 (2.0) 3 (3.0) 6 (6.0) 11 (11.0) 25 (25.0) 41 (41.0) 12 (12.0) 78.0 69.9–86.1
Competency 4:Because of the Climate Change, Environment, and Health curricular theme, I am better able to describe the ways in which the healthcare system contributes to climate change and how healthcare delivery is vulnerable to climate-related events. 2 (2.0) 4 (4.0) 4 (4.0) 12 (12.0) 21 (21.0) 46 (46.0) 11 (11.0) 78.0 69.9–86.1
Competency 5:Because of the Climate Change, Environment, and Health curricular theme, I am better prepared to explore roles health professionals and institutions can play in climate solutions. 2 (2.0) 2 (2.0) 8 (8.0) 17 (17.0) 27 (27.0) 34 (34.0 10 (10.0) 71.0 62.1–79.9

a There were 101 respondents to this survey question

 Outcomes and results Formal curricular theme status

In 2022, the HMS curriculum formally recognized six curricular themes: Health Equity and Antiracism, Aging and End of Life, Sexual and Gender Minority Health, Substance Use and Pain, Trauma Informed Care, and Interprofessional Education. In January 2023, the HMS Educational Policy and Curriculum Committee approved a seventh curricular theme—Climate Change, Environment, and Health. This approval provided the curriculum with formal institutional status, and thereby created a mandate to integrate required content throughout all four years of the medical school curriculum. A new faculty theme director role was established with financial and administrative support from the HMS Office of Medical Education.

 Retrospective data

We found that 94.1% of study participants agreed (defined here as somewhat agree, agree, or strongly agree) that understanding how climate change impacts human health should be part of all students’ medical education (Table 3). Furthermore, 76.0% agreed that the Climate Change, Environment, and Health curriculum theme was valuable, and 80.0% agreed the theme improved their understanding of the health impacts of climate change. We also found that most students agreed that their abilities in each of the five competencies had improved because of their exposure to the curricular theme.

While the qualitative data collected do not meet standards for systematic analysis, there are several informative themes that emerged from review of open-ended comments. Broadly, these themes include a sense that the curricular integrations were: valuable and important to students’ learning in this domain (number of corresponding comments, N = 18); too simple in scope or would have benefited from further nuance (N = 4); not convincingly relevant to the health of Americans (N = 1); not adequately interactive (N = 2); and too limited/additional sessions would have been welcome (N = 3), especially on health equity topics (N = 2).

 Discussion

Students and faculty at HMS were successful in substantially increasing climate content in the pre-clerkship phase, creating a novel competency framework, and ultimately getting a formal institutional commitment for a longitudinal, integrated Climate Change, Environment, and Health curricular theme. Survey data showed that a substantial majority of students agreed that the curriculum was important and valuable, highlighting broad support for our efforts from students. Students largely agreed that the curriculum improved capacity in each of the defined competencies of our framework. However, survey data also showed that a portion (between 18.8% and 35%) of respondents only “somewhat agreed” with the prompts. Additionally, qualitative feedback provided suggestions for areas for improvement.

Having formal theme status at HMS supported effective and synergistic collaboration between students, the CHFWG, course directors and deans in the Office of Medical Education. Student leadership catalyzed both the initiation and development of the curricular theme. Now, as a curriculum with institutional support, the curricular theme seeks to be student-inclusive but not student-dependent. Content expertise from the CHFWG facilitated the depth and breadth of curricular offerings. Significant buy-in and collaboration from course directors and deans provided critical formal institutional support. Furthermore, students and the CHFWG began the process of obtaining formal institutional commitment early on. Achieving recognition as a formal theme status was a critical step in accelerating the pace of curricular development in its first year.

Areas to further strengthen the pre-clerkship curriculum include integrating lifespan approaches, organ-specific approaches, and more detailed teaching of health inequities faced by vulnerable populations. We also seek to increase climate-related skills through project-based learning in areas such as critical thinking, clinical assessment, and health advocacy. It will also be important to create more mentorship opportunities that help students interested in this work reflect on how they can incorporate it into their careers. Previous literature has highlighted the importance of these pedagogical approaches [5–9, 11, 12].

With an established first-year, pre-clerkship curriculum in place, further development is underway for the HST track curriculum and the clerkship and post-clerkship phases. Additionally, CHFWG is developing more structured opportunities for mentored projects and career development. We are collaborating with colleagues engaged in university-wide interdisciplinary climate curricular reform efforts across Harvard University. We have received institutional approval to conduct longitudinal surveys to evaluate future cohorts’ experiences of each component of the curriculum, which will allow us to better assess whether each curricular integration meets its objectives and will guide iterative refinement of the curriculum. The retrospective data presented in this manuscript has limitations in that it was a single cross-sectional survey assessment that was delivered at the end of a year of curricular integrations. As the survey was optional, not all students completed it, with a response rate of 74.6%. This response rate may have introduced bias, if those who did not fill out the survey were qualitatively different than those who did. A more detailed, longitudinal survey and a systematic process for qualitative data collection and analysis would be helpful to examining the strengths and weaknesses of each curricular integration.

Given the early phase of curricular innovation in this area, additional scholarship is needed to present different curricular approaches and competency frameworks at all levels of undergraduate, graduate, and continuing climate medical education. Such scholarship may further the development of broadly accepted competency models that can be utilized by medical schools and accreditation bodies. Our work in developing a competency-based, longitudinal, integrated curricular theme is relevant not only for physician training, but for interdisciplinary health professions, many of which are working to significantly expand climate education in their respective fields. Greater implementation of climate medical education and standardization of competencies may help to more effectively train future physicians to understand and respond to the impacts of climate change on health and health equity.

 Supporting information Raw retrospective survey data.

(XLSX)

The authors wish to thank Dr. Edward M. Hundert, Dr. Bernard Chang, and the Office of Medical Education at Harvard Medical School for their support of this initiative.

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Mapping climate change and health into the medical curriculum: co-development of a “planetary health–organ system map” for graduate medical education [Internet]. medRxiv; 2021 [cited 2024 Mar 8]. p. 2021.11.23.21265688. Available from: https://www.medrxiv.org/content/10.1101/2021.11.23.21265688v1 Hansen M, Rohn S, Moglan E, Sutton W, Olagunju AT. Promoting climate change issues in medical education: Lessons from a student-driven advocacy project in a Canadian Medical school. The Journal of Climate Change and Health. 2021 Aug 1;3:100026. Omrani OE, Dafallah A, Paniello Castillo B, Amaro BQRC, Taneja S, Amzil M, et al. Envisioning planetary health in every medical curriculum: An international medical student organization’s perspective. Medical Teacher. 2020 Oct 2;42(10):1107–11. doi: 10.1080/0142159X.2020.1796949 32757869 Bevan J, Blyth R, Russell B, Holtgrewe L, Cheung AHC, Austin I, et al. Planetary health and sustainability teaching in UK medical education: A review of medical school curricula. Medical Teacher. 2023 Jun 3;45(6):623–32. doi: 10.1080/0142159X.2022.2152190 36503358 Nordrum OL, Kirk A, Lee SA, Haley K, Killilea D, Khalid I, et al. Planetary health education in medical curricula in the Republic of Ireland. Medical Teacher. 2022 Nov 2;44(11):1237–43. doi: 10.1080/0142159X.2022.2072279 35583294 Létourneau S, Roshan A, Kitching GT, Robson J, Walker C, Xu C, et al. Climate change and health in medical school curricula: A national survey of medical students’ experiences, attitudes and interests. The Journal of Climate Change and Health. 2023 May;11:100226. Colbert CY, French JC, Brateanu A, Pacheco SE, Khatri SB, Sapatnekar S, et al. An Examination of the Intersection of Climate Change, the Physician Specialty Workforce, and Graduate Medical Education in the U.S. Teaching and Learning in Medicine. 2022 Jun 14;34(3):329–40. Wheat S, Chekuri B, Sorensen C, Rochford R, Lemery J. Creating climate-informed physician leaders: The evolution of a physician fellowship in climate and health science policy. Frontiers in Medicine [Internet]. 2022 [cited 2024 Mar 8];9. Available from: https://www.frontiersin.org/articles/10.3389/fmed.2022.1060145 36606054 Basu G, Stojicic P, Goldman A, Shaffer J, McCormick D. Health Professionals Organizing for Climate Action: A Novel Community Organizing Fellowship. Academic Medicine. 2023 Oct 16; doi: 10.1097/ACM.0000000000005637 38228058 Mallon B, Cox, Natalya. Climate Action in Academic Medicine: An overview of how medical schools and teaching hospitals and health systems are responding to climate change [Internet]. Washington, DC: AAMC; 2022 Nov. Available from: https://www.aamc.org/media/64106/download?attachment Navarrete-Welton A, Chen JJ, Byg B, Malani K, Li ML, Martin KD, et al. A grassroots approach for greener education: An example of a medical student-driven planetary health curriculum. Frontiers in Public Health [Internet]. 2022 [cited 2023 Sep 20];10. Available from: https://www.frontiersin.org/articles/10.3389/fpubh.2022.1013880 36225779 Rabin BM, Laney EB, Philipsborn RP. The Unique Role of Medical Students in Catalyzing Climate Change Education. Journal of Medical Education and Curricular Development. 2020 Jan 1;7:2382120520957653. doi: 10.1177/2382120520957653 33134547 Jowell A, Lachenauer A, Lu J, Maines B, Patel L, Nadeau K, et al. A model for comprehensive climate and medical education. The Lancet Planetary Health. 2023 Jan 1;7(1):e2–3 doi: 10.1016/S2542-5196(22)00215-7 36608944 Sullivan JK, Lowe KE, Gordon IO, Colbert CY, Salas RN, Bernstein A, et al. Climate Change and Medical Education: An Integrative Model. Academic Medicine. 2022 Feb;97(2):188. doi: 10.1097/ACM.0000000000004376 34432714 McLean M, Behrens G, Chase H, El Omrani O, Hackett F, Hampshire K, et al. The Medical Education Planetary Health Journey: Advancing the Agenda in the Health Professions Requires Eco-Ethical Leadership and Inclusive Collaboration. Challenges. 2022 Dec;13(2):62. Kligler SK, Clark L, Cayon C, Prescott N, Gregory JK, Sheffield PE. Climate change curriculum infusion project: An educational initiative at one U.S. medical school. The Journal of Climate Change and Health. 2021 Oct 1;4:100065. Hirsh D, Gaufberg E, Ogur B, Cohen P, Krupat E, Cox M, et al. Educational Outcomes of the Harvard Medical School–Cambridge Integrated Clerkship: A Way Forward for Medical Education. Academic Medicine. 2012 May;87(5):643. doi: 10.1097/ACM.0b013e31824d9821 22450189 Madan CR. Using Evidence-Based Learning Strategies to Improve Medical Education. MedSciEduc. 2023 Jun 1;33(3):773–6. doi: 10.1007/s40670-023-01798-9 37501813 Rohrer D. Interleaving Helps Students Distinguish among Similar Concepts. Educ Psychol Rev. 2012 Sep 1;24(3):355–67. 10.1371/journal.pclm.0000412.r001 Decision Letter 0 Harper Sherilee L. Academic Editor 2024 Sherilee L. Harper This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version 0

19 Feb 2024

PCLM-D-23-00235

Climate Change, Environment, and Health: The Implementation and Initial Evaluation of a Longitudinal, Integrated Curricular Theme and Novel Competency Framework at Harvard Medical School

PLOS Climate

Dear Dr. Basu,

Thank you for submitting your manuscript to PLOS Climate. After careful consideration, we feel that it has merit but does not fully meet PLOS Climate’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Apr 04 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at climate@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pclm/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Sherilee L. Harper, PhD

Academic Editor

PLOS Climate

Journal Requirements:

1. May we please request of copy editing.

Additional Editor Comments (if provided):

Thank you for submitting your article to the journal. It covers an important topic.

After reading the reviewer comments, and based on my own assessment of the article, I would like to invite you to make revisions to your article.

In addition to the great and helpful comments of the reviewers, it would be helpful if could you also please include information in the article about your ethics approvals and any important ethical details.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does this manuscript meet PLOS Climate’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS Climate does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: My thanks to the authors for their commendable development of what appears to be a leading example of integrating climate change into medical education. In general, the paper is well-written, and compelling in terms of how it has documented the success of the program's rollout. I have two major suggestions for revision and several minor suggestions that would significantly enhance the manuscript and increase its suitability for publication in PLOS Climate:

Major issues:

There is a slightly problematic orientation of the authors in labeling what they’ve done as particularly novel and inventive, primarily because of under engagement with the ever-growing literature on this topic, much of which did not seem to be considered during the planning and implementation phase. This is not to take away from what I do believe is an exemplary mainstreaming of climate into Harvard's medical program which is a significant contribution. However, in terms of the manuscript, there are opportunities to recast and reposition the exemplary contribution to medical education that is articulated in this contribution by better placing it in context of other empirical and conceptual work around climate change core competencies and expanded opportunities for medical education (including public health and nursing professions) which would be a bit more mindful of past precedent in this space. Cross-referencing the extant literature, and more importantly, identifying existing gaps and opportunities to further strengthen your curriculum (or at least make recommendations to others based on which gaps emerge from a more adequate review of the literature, for example) would significantly enhance the utility and communicative potential of your paper. Such a review should also be mindful of incorporating perspectives from other allied health professions, including nursing and public health (the latter of which has been notably more active in this space). See for example:

3.

Montero-Pau J, Álvaro N, Gavidia V, Mayoral O. Development of Environmental Health Competencies through Compulsory Education. A Polyhedral Approach Based on the SDGs. Sustainability. 2020 Apr 16;12(8):3215.

4.

Maxwell J, Blashki G. Teaching about Climate Change in Medical Education: An Opportunity. Journal of Public Health Research. 2016 Apr 26;5(1):jphr.2016.673.

5.

Leffers J, Levy RM, Nicholas PK, Sweeney CF. Mandate for the Nursing Profession to Address Climate Change Through Nursing Education: Climate Change Nursing Education. Journal of Nursing Scholarship. 2017 Nov;49(6):679–87.

6.

Lomazzi M. A Global Charter for the Public’s Health—the public health system: role, functions, competencies and education requirements*. Eur J Public Health. 2016 Apr;26(2):210–2.

7.

Jagals P, Ebi K. Core Competencies for Health Workers to Deal with Climate and Environmental Change. IJERPH. 2021 Apr 7;18(8):3849.

8.

Czabanowska K, Kuhlmann E. Public health competences through the lens of the COVID‐19 pandemic: what matters for health workforce preparedness for global health emergencies. Int J Health Plann Mgmt. 2021 May;36(S1):14–9.

9.

Bell EJ. Climate change: what competencies and which medical education and training approaches? BMC Med Educ. 2010 Dec;10(1):31.

10.

Ansari W, Stibbe A. Public Health and the Environment: What Skills for Sustainability Literacy – And Why? Sustainability. 2009 Aug 6;1(3):425–40.

1.

Bevan J, Blyth R, Russell B, Holtgrewe L, Cheung AHC, Austin I, et al. Planetary health and sustainability teaching in UK medical education: A review of medical school curricula. Medical Teacher. 2022 Dec 12;0(0):1–10.

1.

Burch H, Watson B, Simpson G, Beaton LJ, Maxwell J, Winkel K. Mapping climate change and health into the medical curriculum: co-development of a “planetary health – organ system map” for graduate medical education [Internet]. medRxiv; 2021 [cited 2023 Apr 3]. p. 2021.11.23.21265688. Available from: https://www.medrxiv.org/content/10.1101/2021.11.23.21265688v1

2.

Colbert CY, French JC, Brateanu A, Pacheco SE, Khatri SB, Sapatnekar S, et al. An Examination of the Intersection of Climate Change, the Physician Specialty Workforce, and Graduate Medical Education in the U.S. Teaching and Learning in Medicine. 2022 May 27;34(3):329–40.

3.

Hansen M, Rohn S, Moglan E, Sutton W, Olagunju AT. Promoting climate change issues in medical education: Lessons from a student-driven advocacy project in a Canadian Medical school. The Journal of Climate Change and Health. 2021 Aug 1;3:100026.

4.

Hess JJ, Heilpern KL, Davis TE, Frumkin H. Climate Change and Emergency Medicine: Impacts and Opportunities. Academic Emergency Medicine. 2009;16(8):782–94.

5.

Lapaige V, Essiembre H. Innoversity in knowledge-for-action and adaptation to climate change: the first steps of an “evidence-based climatic health” transfrontier training program. Adv Med Educ Pract. 2010;1:89–105.

6.

Létourneau S, Roshan A, Kitching GT, Robson J, Walker C, Xu C, et al. Climate change and health in medical school curricula: A national survey of medical students’ experiences, attitudes and interests. The Journal of Climate Change and Health. 2023 May 1;11:100226.

8.

McLean M, Behrens G, Chase H, El Omrani O, Hackett F, Hampshire K, et al. The Medical Education Planetary Health Journey: Advancing the Agenda in the Health Professions Requires Eco-Ethical Leadership and Inclusive Collaboration. Challenges. 2022 Dec;13(2):62.

10.

Nordrum OL, Kirk A, Lee SA, Haley K, Killilea D, Khalid I, et al. Planetary health education in medical curricula in the Republic of Ireland. Medical Teacher. 2022 Nov 2;44(11):1237–43.

11.

Omrani OE, Dafallah A, Paniello Castillo B, Amaro BQRC, Taneja S, Amzil M, et al. Envisioning planetary health in every medical curriculum: An international medical student organization’s perspective. Medical Teacher. 2020 Oct 2;42(10):1107–11.

12.

Oudbier J, Sperna Weiland NH, Boerboom T, Ravesloot JH, Peerdeman S, Suurmond J. An evidence-based roadmap to integrate planetary health education into the medical curriculum. Medical Teacher. 2023 Mar 4;45(3):328–32.

13.

14.

Wheat S, Chekuri B, Sorensen C, Rochford R, Lemery J. Creating climate-informed physician leaders: The evolution of a physician fellowship in climate and health science policy. Front Med. 2022 Dec 20;9:1060145.

1.

ASPHER CLimate and Health Competencies for Public Health Professionals in Europe [Internet]. Available from: https://www.aspher.org/download/882/25-10-2021-final_aspher-climate-and-health-competencies-for-public-health-professionals-in-europe.pdf

2.

Patrick R, Capetola T, Townsend M, Nuttman S. Health promotion and climate change: exploring the core competencies required for action. Health Promotion International. 2012 Dec 1;27(4):475–85.

The other major issue is in terms of how the authors handle counterfactuals in their reported evaluation data. L238 - I find it a bit unfortunate that you only report on your positive results, when in fact, there are counterfactuals present. It would be valuable to explore the perceptions of those respondents with qualitative data to better understand the contextually relevant aspects of those student experiences and more importantly, understand potential roadblocks and challenges associated with incorporating this material into the curriculum, or at a minimum, to report to readers whether this is possible based on what was collected or why this occurred at all.

Minor Issues:

L119 - was your pilot lesson an example of case based learning? Can you provide more detail here? How was it evaluated

L143 - suggest recasting your use of ‘longitudinal’ throughout your paper given that this word has strong associations with approaches to continued data collection in research. I think you mean that you are embedding a climate focus across their training experience. Perhaps ‘continued and successive integration of climate into medical education’ is more descriptive?

L144- please expand upon these points - what are spacing and interleaving and why were they selected of any multitude of pedagogical concepts that could have been deployed? What was your process for arriving at these two, specifically?

L155-162 - really great that you have this more structural and community-oriented lens in your training program!

L165-178 - how was the initial integration evaluated? How did you know that it worked and what if instructors and course directors ran into road blocks? Did instructors require training to implement case based learning and how was this achieved?

Reviewer #2: This paper provides pragmatic insight on an approach to addressing climate change and health in medical education. Sharing both the process and the outcomes of these efforts is important information for other faculties, who are either currently working on this or will be soon. A number of minor revisions have been suggested below, mainly focused on strengthening/improving clarity.

Overall:

1. There are a number of terms used in the paper that are not necessarily universal (tracks, clerkship, Pathways). Please ensure that they are clearly defined and used consistently throughout

Approach and Methods:

1. Is there an overarching pedagogical approach(es) used to generally guide the curriculum (i.e. inquiry-based, integrative, etc)? If so, how was your work guided by that?

2. The paper identifies “spacing” and “interleaving” as pedagogical principles; consider defining these as tools to enhance memory and attention

3. Did you consult existing pedagogical frameworks relevant to this topic (i.e. Planetary Health Education Framework)? If not, this may be something to consider for future work.

4. Additional information on survey delivery is recommended:

o How was the survey delivered to students?

o Was being a Pathways student the only eligibility criteria for participating in the survey?

o Why only 100 responses?

o When was the survey delivered in relation to when the courses were completed?

5. Consider dividing Table 3 into a table that identifies the list of questions asked, and a figure that presents the results of the survey (placed in the “outcomes and results” section).

Outcomes and results:

1. Are there any learnings to be shared about the process of gaining status as a formal curricular theme (i.e. crucial information to build the case)?

2. Please put the information on formal curricular theme status in the context of the timeline of the work outlined in the study, so that the connection between the educational intervention and adopting a new curricular theme is easily understood

Discussio

 10.1371/journal.pclm.0000412.r002 Author response to Decision Letter 0 Submission Version 1

13 Mar 2024

Submitted filename: Response to Reviewers.docx

 10.1371/journal.pclm.0000412.r003 Decision Letter 1 Harper Sherilee L. Academic Editor 2024 Sherilee L. Harper This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version 1

18 Apr 2024

Climate Change, Environment, and Health: The Implementation and Initial Evaluation of a Longitudinal, Integrated Curricular Theme and Novel Competency Framework at Harvard Medical School

PCLM-D-23-00235R1

Dear Dr. Basu,

We are pleased to inform you that your manuscript 'Climate Change, Environment, and Health: The Implementation and Initial Evaluation of a Longitudinal, Integrated Curricular Theme and Novel Competency Framework at Harvard Medical School' has been provisionally accepted for publication in PLOS Climate.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow-up email from a member of our team. 

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they'll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact climate@plos.org.

Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Climate.

Best regards,

Sherilee L. Harper, PhD

Academic Editor

PLOS Climate

***********************************************************

Thank you for revising your submission. I agree with both of the reviewers: the authors have done an excellent job revising their article and responding to reviewer comments.

Reviewer Comments (if any, and for reference):

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Does this manuscript meet PLOS Climate’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS Climate does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: My thanks to the authors for attending to the important changes outlined by reviewers. I find the current manuscript considerably improved after revision, and suitable for publication in PLOS Climate.

Reviewer #2: Thank you for your responses

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

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